Patient Agreement & Informed Consent | Financial Policy | Privacy Practices | Child Treatment Policy | Telehealth Policy
PATIENT AGREEMENT & INFORMED CONSENT
Welcome to our practice. This document (the Agreement) contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail, and our practice is in general accordance with HIPAA policies. The law requires that we obtain your signature acknowledging that we have provided you with this information.
MENTAL HEALTH SERVICES
Therapy is a relationship between people that works in part because of the clearly defined rights and responsibilities held by each person. Our goal is to create a safe space where you will be supported and empowered to create change. As a client in psychotherapy and/or psychiatry, you have certain rights and responsibilities that are important for you to know about. There are also legal limitations to those rights. We, as your provider(s), have corresponding responsibilities for you. These respective rights are described in the following section.
Mental health treatment has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. Mental health treatment often requires discussing unpleasant aspects of your life. However, mental health treatment has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. But, there are no guarantees about what will happen. Mental health treatment requires a very active effort on your part. Our success IN session often requires thoughtful OUT of session work and exploration on your part.
APPOINTMENTS
The first few sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, your provider will be able to offer you some initial impressions of what your treatment may include. During this time, you can both decide if your provider is the best person to provide the services you need in order to meet your treatment goals. If treatment is begun, your provider will usually schedule one 45-minute session (one appointment hour of 45 minutes duration) per week at a time agreed upon, although some sessions may be longer or more/less frequent. If medication management is begun, your provider will usually schedule follow up meetings with you at varying intervals to continually assess for effectiveness of treatment. Please note that your provider may, at the provider’s sole discretion, determine at the first or any subsequent session, that you require a higher level of care or treatment beyond what can be provided in our outpatient private practice. In such a case, your provider is bound by ethical duty to refer you for treatment that more closely meets your needs.
INSURANCE
We accept payment directly from insurance companies. As a courtesy we are happy to bill most insurance companies directly for our services with the understanding that you remain financially responsible for any payment not made by your insurance carrier. Insurance companies often require a formal diagnosis with their claims. Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. Please feel free to discuss your diagnosis with your provider.
PROFESSIONAL RECORDS
Your provider(s) are required to keep appropriate records of the mental health services that they provide. Although mental health treatment often includes discussions of sensitive and private information, normally very brief records are kept noting that you have been here, what was done in session, and a mention of the topics discussed. You have the right to a copy of your file at any time. You have the right to request that a copy of your file be made available to any other health care provider at your written request. Your records are maintained in a secure location in the office. We utilize an electronic medical record system (EMR) that securely houses patient information.
CONFIDENTIALITY
The confidentiality of all communications between a client and mental health provider is generally protected by law. Eugene Therapy/Oregon Counseling and your provider(s), cannot and will not tell anyone else what you have discussed or even that you are in treatment without your written permission. In most situations, Eugene Therapy/Oregon Counseling and your provider(s) can only release information about your treatment to others outside of the practice if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. Providers at Eugene Therapy/Oregon Counseling, may share your clinical information when consulting with one another and/or when coordinating your care when it is deemed in their professional judgment, to be clinically appropriate. All members of the group Eugene Therapy/Oregon Counseling are bound by the laws and rules surrounding confidentiality for their given licenses and by the terms of this statement. With the exception of certain specific situations described below, you have the right to confidentiality of your treatment. You, on the other hand, may request that information is shared with whomever you choose and you may revoke that permission in writing at any time. There are, however, several exceptions in which your provider is legally bound to take action even though that requires revealing some information about a patient's treatment. If at all possible, your provider will make every attempt to inform you when these will have to be put into effect. The legal exceptions to confidentiality include, but are not limited, to the following:
1. If there is good reason to believe you are threatening serious bodily harm to yourself or others. If a provider believes a client is threatening serious bodily harm to another, the provider may be required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a client threatens harm to him/herself or another, the provider may be required to seek hospitalization for the client, or to contact family members or others who can provide protection.
2. If there is good reason to suspect, or evidence of, abuse and/or neglect toward children, the elderly or disabled persons. In such a situation, your provider is required by law to file a report with the appropriate state agency.
3. In response to a court order or where otherwise required by law.
4. To the extent necessary, to make a claim on a delinquent account via a collection agency.
5. To the extent necessary for emergency medical care to be rendered.
Finally, there are times when your provider may find it beneficial to consult with colleagues as part of a peer-consultation practice for mutual professional consultation. Your name and unique identifying characteristics will not be disclosed. The consultant is also legally bound to keep the information confidential.
CONTACTING YOUR PROVIDER
Your provider is often not immediately available by telephone but reception is typically available from 9 AM to 5PM, Monday through Friday. During times when no one is available to take your call, please leave a message and your call will be returned within the next business day. In an emergency, please call 911 or proceed to the nearest emergency room. For urgent matters, please call the office phone for further instructions. Please note medication refills are not considered urgent, and will be handled within 5 business days.
But, for any number of unseen reasons, if you do not hear from your provider or your provider is unable to reach you, it remains your responsibility to take care of yourself until such time as you and your provider can talk. If you feel unable to keep yourself safe, go to your nearest emergency room. Your provider will make every attempt to inform you in advance of any planned absences, and provide you with a name and phone number of the provider covering the practice.
CONSENT TO TEXT MESSAGING AND EMAIL
In order to enhance patient care, our practice may contact you via phone call, voicemail, SMS text message, e-mail, or mobile application, some of which may be via automated means to remind you of an appointment, to obtain feedback on your experience with our mental healthcare team, and to provide other information. You understand and agree to be contacted in this manner with communications related to your initial and any future appointments. In the future, you may opt-out of receiving messages by notifying us in writing via text to 541-868-2004 or by emailing us at hello@eugenetherpay.com or hello@oregoncounseling.com.
WAITING ROOM SAFETY AND VIDEO SURVEILLANCE
At Eugene Therapy/Oregon Counseling, you understand and consent to video surveillance for security purposes and/or the practice’s health care operations. You understand the facility retains ownership rights to the images and/or recordings. You understand that these images and/or recordings will be securely stored and protected and are limited to use in our public waiting room spaces.
OTHER RIGHTS
If you are unhappy with what is happening in mental health treatment, please discuss this with your therapist so that he/she can respond to your concerns. Such criticism will be taken seriously and with care and respect. You may also request that you be referred to another therapist and are free to end therapy at any time.
You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment.
You have the right to ask questions about any aspect of the mental health treatment and about your provider's specific training and experience. You have the right to expect that your provider will not have social or sexual relationships with clients or with former clients.
FINANCIAL POLICY
Patients of Eugene Therapy and OregonCounseling are required to:
- Present an insurance card at the time of service
- Present a picture ID (driver's license preferred) for verification of identity
- Inform us immediately if the patient's insurance carrier changes and provide us with a copy (front and back) of the new card.
- Pay the correct co-pay, co-insurance and/or un-met deductibles at the TIME OF SERVICE. We are required by our insurance contract to collect patient copays.
- Assume financial responsibility for any and all charges your health insurance company does not pay for. This includes patient co-pay, co-insurance, policy deductible, and any and all non-covered services and the outstanding balance after the insurance company has submitted payment to Eugene Therapy/Oregon Counseling.
- Keep a valid credit card on file with Eugene Therapy/Oregon Counseling to be used for any account balance including co-pays, co-insurance, deductibles, late cancel fees and/or no show fees.
- Pay the account balance in full immediately upon receiving a statement from Eugene Therapy/Oregon Counseling of outstanding charges. An unpaid balance above $200 may result in termination from the practice.
RESPONSIBILITY FOR PAYMENT
Even though a patient may have health insurance, the patient is the guarantor and the patient is responsible for payment of services provided by Eugene Therapy/Oregon Counseling. Eugene Therapy/Oregon Counseling will bill the patient's PRIMARY insurance company in most circumstances for all services rendered with the information the patient has provided. The patient is responsible for notifying us immediately if insurance information has changed, so we may bill the correct insurance carrier. Once the insurance company has processed the patient's claim, Eugene Therapy/Oregon Counseling will post any payment it receives to the patient's account. If there is a remaining balance, the balance will become the patient's responsibility and is due immediately upon receipt. This balance may include deductibles, co-insurance and any and all non-covered charges. Payment for this balance is due immediately upon the patient's receiving our statement of outstanding charges. Should a balance accrue and no payment is received, Eugene Therapy/Oregon Counseling reserves the right to terminate services for non-payment and/or seek remuneration by any means legally possible including, but not limited to, the retention of a collection agency.
FEES
Counseling sessions with a licensed therapist are billed at $100 to $200; Therapy sessions with a licensed Psychologist are billed at $150 to $300; Psychiatric sessions with a Psychiatric Nurse Practitioner are billed at $150 to $350; Pre-licensed therapist fees are $60 to $100 per 45 minute session; and graduate student intern therapist fees are $25 to $60 per 45 minute session. Fees will be re-evaluated periodically
In the case that an insurance company is being billed for services, Eugene Therapy/Oregon Counseling will provide a courtesy benefit check in order to provide the patient with benefit information and the estimated patient contribution. This is not a guarantee of benefits or payment owed; and patients are encouraged to contact their insurance companies to confirm benefits and eligibility. Contracted rates with insurance companies are subject to change.
NO SHOWS AND LATE CANCELLATIONS
Services are most effective when meeting times are regular and consistent. If patients need to cancel or reschedule a session, it is required that they provide 24 hours "Business Day" notice. "Business Day" notice means, for example, that for a Monday cancellation, patients must call by the preceding Friday prior to the hour of the appointment time scheduled on Monday. For a post-holiday cancellation, patients must also call with at least one "Business Day" notice. If a patient misses a session without canceling, or cancel with less than 24 hours "Business Day" notice, the patient will be billed $100 (ONE HUNDRED DOLLARS US). It is important to note that insurance companies do not provide reimbursement for canceled sessions. In addition, patients are responsible for coming to sessions on time and at the time scheduled. If a patient is late, the appointment will still need to end on time. If a patient is more than 20 minutes late to a therapy session or 10 minutes late to an therapy intake session or any psychiatric appointment, the provider may no longer be able to see the patient and the no show fee will apply. If the provider is late, the patient will still receive the full session time. If a patient misses two (2) appointments without providing proper notice, that patient may be discharged from the practice and provided appropriate referrals for care.
PRIMARY INSURANCE CLAIMS
As a courtesy, in most circumstances we will file claims with the patient's primary insurance upon the patient's submission of proof of insurance (insurance card indicating coverage, identification number, group number and subscriber demographics). Exceptions do apply and Eugene Therapy and Oregon Counseling are not at any point obligated to bill any insurance company. In the event the patient has insurance coverage but cannot provide documentation, full payment is due at the time of service. If the insurance company does not pay within 30 days following the date of service, the patient is responsible for the remaining balance. Eugene Therapy/Oregon Counseling reserves the right to require payment in full for out of network services covered by certain insurance carriers with whom Eugene Therapy/Oregon Counseling is NOT a preferred provider organization.
SECONDARY INSURANCE
Eugene Therapy/Oregon Counseling will need to know which insurance is primary. If you are unsure, please contact your insurance company directly to determine this. We only bill secondary insurance with our in-network carriers. We are happy to provide patients with receipts for service so the patient may self submit claims to a secondary carrier.
REFERRALS AND AUTHORIZATIONS
If a patient has an insurance plan that requires a referral from a primary care physician prior and/or an authorization by the insurance company to a visit a mental health professional, it is the patient's responsibility to obtain the referral. If the patient chooses to seek the services of a mental health professional without the referral, the patient will be responsible for the payment of the charges.
CREDIT CARD ON FILE
Patients are required to keep a valid credit card on file and, per this financial agreement, authorize Eugene Therapy/Oregon Counseling to charge the credit card for any unpaid balances including co-pays, coinsurance, deductibles, late cancel fees and/or no show fees, and records fees. If an HSA/FSA benefits card is added, a backup credit/debit card on file must also be added. Practice fees (late cancel/no show fees and records fees) cannot be charged to an HSA/FSA card on file. If an HSA/FSA benefits card declines, we will automatically run the backup card on file for any balances due.
FORMS OF PAYMENT
In order to provide efficient billing services, Eugene Therapy/Oregon Counseling accepts credit card payments only (Visa, MC, Discover, AMEX).
PARENTS/GUARDIANS ARE RESPONSIBLE FOR PAYMENT
Parents/Guardians are responsible for any co-payments, deductibles, and non-covered services. This office considers the parent/guardian bringing the child in for mental health treatment financially responsible for any charges arising for that date of service, regardless of any custody issues. Any court orders regarding responsibility for such costs are to be enforced by the courts and do not determine who we bill for a child's care.
PAYMENT ARRANGEMENTS
Patients unable to pay a patient statement balance in full upon receipt of statement or a copay at the time of the visit are strongly encouraged to contact us at 541-868-2004 to discuss payment options. Unless a payment arrangement is made, the card on file will be charged for the outstanding balance within 5 days.
CHARGES AND FEES FOR ADDITIONAL SERVICES
The following additional services are not covered by your insurance carrier. Payment for these additional fees must accompany any request for the below services. In addition, if there is an outstanding balance on the account, Eugene Therapy/Oregon Counseling will ask the patient to submit payment in full for the outstanding balance.
- Personalized letters and documents including medical necessity letters $50.
Fees for records are determined according to ORS 192.563.
- No-Show/Late Cancel Charge (scheduled and not cancelled 24 hours "Business Day" in advance) $100.
- Phone Consultative Services - billed to you at $200/hour for therapists and $300/hour for psychologists and PMHNPs/MDs (cannot be billed to insurance).
- Payment is required at time of service. We charge a $20 Administrative Surcharge for processing your co-payment after your visit.
COURT APPEARANCES
Court appearances are billed at $250.00 per hour with a minimum charge of eight (8) hours, for a total of two thousand ($2,000.00) dollars. Eugene Therapy/Oregon Counseling's providers, employees, contractors and/or interns will not voluntarily participate in any litigation, or custody dispute in which a client or their representative/guardian and another individual, or entity, are parties. Eugene Therapy/Oregon Counseling's providers will also not make any recommendation as to custody or visitation regarding our clients. Because the client-mental health provider relationship is built on trust with the foundation of that trust being confidentiality, it is often damaging to the therapeutic relationship for the mental health provider to be asked to present records to the court, testify whether factual or in an expert nature, in court or deposition. The mental health provider asks that clients only request a court appearance in extreme cases. Unfortunately, this will likely, result in the need to terminate mental health treatment and refer you to another mental health provider. In such cases as the mental health provider is ordered to testify by the court about his/her counseling with you, the mental health provider will be monetarily compensated as set forth below.
In the event that it is necessary for the mental health provider to testify before any court, arbitrator, or other hearing officer to testify at a deposition, whether the testimony is factual or expert, or to present any or all records pertaining to the counseling relationship to a court official, the client agrees to pay the therapist for his or her services, including travel, preparation, and necessary expenditures (copies, parking, meals, and the like) @ the rate of $250.00 per hour, rounded to the nearest half hour. The client further agrees to pay the $2,000.00 (8 hours x $250.00) two weeks prior to the appearance, presentation of records, or testimony requested. This will be the case even if the therapist is called to testify by another party.
CHILD TREATMENT POLICY AND PARENTAL AGREEMENT TO CHILD'S PRIVACY
Prior to beginning treatment, it is important for you to understand Eugene Therapy/Oregon Counseling's approach to child therapy and agree to some guidelines about your child's confidentiality during the course of treatment. The information herein is in addition to the information contained in the Patient Agreement and Informed Consent document. Under HIPAA and the ethical codes of our profession, we are legally and ethically responsible to provide you with informed consent.
One risk of child mental health treatment involves disagreement among parents and/or disagreement between parents and mental health provider regarding the best interests of the child. If such disagreements occur, Eugene Therapy/Oregon Counseling will strive to listen carefully so that we can understand your perspectives and fully explain our perspective. Our goal is to enable your child's therapeutic progress. Ultimately, you will decide whether mental health treatment will continue. Should you decide that mental health treatment of your child should end, we will honor that decision, and ask that you allow Eugene Therapy/Oregon Counseling the option of having up to a few closing sessions to appropriately end the treatment relationship.
Mental health treatment is most effective when a trusting relationship exists between the therapist and the patient. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger and better relationship between children and their parents. However, it is often necessary for children to develop a ‘zone of privacy' whereby they feel free to discuss personal matters with greater freedom. While this is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy, this is our policy for ALL children under the age of 18 years of age.
It is our policy to provide you with general information about treatment status. We will raise issues that may impact your child either inside or outside the home. If it is necessary to refer your child to another mental health professional with more specialized skills, we will share that information with you. We will not share with you what your child has disclosed to us without your child's consent, unless, in our best judgement, it rises to a level of serious risk to your child. We will tell you if your child does not attend sessions. At the end of your child's treatment we will, upon your request, provide you with a treatment summary that will describe what issues were discussed, what progress was made, and what areas are likely to require intervention in the future.
If your child is an adolescent, it is possible that he/she will reveal sensitive information regarding sexual contact, alcohol and drug use, or other potentially problematic behaviors. Sometimes these behaviors are within the range of normal adolescent experimentation, but at other times they may require parental intervention. We must carefully and directly discuss your feelings and opinions regarding acceptable behavior. If we ever believe that your child is at serious risk of harming him/herself or another, we will inform you.
Although our responsibility to your child may require our involvement in conflicts between the two of you, our involvement will be strictly limited to that which will benefit your child. This means, among other things, that you will treat anything that is said in session with us as confidential and that you will not attempt to gain advantage in any legal proceeding regarding custody or parental rights from our treatment of your child. In particular, we need your agreement that in any such proceedings, neither of you will ask us to testify in court, whether in person, or by affidavit. You also agree to instruct your attorneys not to subpoena us or to refer in any court filing to anything we have said or done.
Note that such agreement may not prevent a judge from requiring our testimony, even though we will work to prevent such an event. If we are required to testify, we are ethically bound not to give our opinion about either parent's custody or visitation suitability. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, we will provide information as needed (if appropriate releases are signed or a court order is provided), but we will not make any recommendation about the final decision. Furthermore, if we are required to appear as a witness, the party responsible for our participation agrees to reimburse Eugene Therapy/Oregon Counseling at the rate of $250.00 per hour with a minimum charge of eight (8) hours, for a total of two thousand ($2,000.00) dollars in consideration for time spent traveling, preparing reports, testifying, being in attendance, legal and peer consultation and any other case-related costs.
PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. OUR RESPONSIBILITIES:
We reserve the right to change this Notice of Privacy Practices and to make any new Notice of Privacy Practices effective for all protected health information that we maintain. Any new Notice of Privacy Practices adopted can be made available at your next appointment.
II. WHAT IS PROTECTED HEALTH INFORMATION (PHI)?
Protected health information ("PHI") is demographic and individually identifiable health information that will or may identify the patient and relates to the patient's past, present or future physical or mental health or condition and related health care services.
III. USES AND DISCLOSURES OF INFORMATION
Under federal law, we are permitted to use and disclose personal health information without authorization for treatment, payment and health care operations.
IV. WHAT DOES "HEALTH CARE OPERATIONS" INCLUDE?
Health care operations include activities such as communications among health care providers, conducting quality assessment and improvement activities; evaluating the qualifications, competence, and performance of healthcare professionals; training future healthcare professionals; other related services that may be a benefit to you such as case management and care coordination; contracting with insurance companies: conducting medical review and auditing services; compiling and analyzing information in anticipation of or for use in legal proceedings; and general administrative and business functions.
V. HOW IS MEDICAL INFORMATION USED?
We use medical records as a way of recording health information, planning care and treatment and as a tool for routine healthcare operations. Your insurance company may request information such as procedure and diagnosis information that we are required to submit in order to bill for treatment we provide to the patient. Other health care providers or health plans reviewing your records must follow the same confidentiality laws and rules required of us. Patient records are also a valuable tool used by researchers in finding the best possible treatment for diseases and medical conditions. All researchers must follow the same rules and laws that other health care providers are required to follow to ensure the privacy of patient information. Information that may identify patients will not be released for research purposes to anyone without written authorization from the patient or the patient's parent or legal guardian.
VI. HOW MEDICAL INFORMATION MAY BE USED FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS
* Medical information may be used to justify needed patient care services, (i.e., lab tests, prescriptions, treatment protocols, research inclusion criteria).
* We will use medical information to establish a treatment plan.
* We may disclose protected health information to another provider for treatment (i.e. referring physicians, specialists and providers, therapists, etc.)
* We may submit claims to your insurance company containing medical information and we may contact their utilization review department to receive pre-certification (prior approval for treatment).
* We will submit only the minimum amount of information necessary for this purpose.
* We may use the emergency contact information you provided to contact you if the address of record is no longer accurate.
* We may contact you to remind you of your appointment by calling, emailing or texting you.
* We may contact you to discuss treatment alternatives or other health related benefits that may be of interest.
VII. WHY DO I HAVE TO SIGN A CONSENT FORM?
When you, as the patient or guardian of a patient, sign a consent form, you are giving us permission to use and disclose protected health information for the purposes of treatment, payment and health care operations. This permission does not include psychotherapy notes, psychosocial information, alcoholism and drug abuse treatment records and other privileged categories of information which require a separate authorization. You will need to sign a separate authorization to have protected health information released for any reason other than treatment, payment or healthcare operations.
VIII. WHAT ARE PSYCHOTHERAPY NOTES?
Psychotherapy notes are notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session that are separated from the rest of the patient's medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
IX. WHAT IS PSYCHOSOCIAL INFORMATION?
Psychosocial information is information provided regarding your social history and counseling or psychiatric services you have received before treatment with me.
X. WHY DO I HAVE TO SIGN A SEPARATE AUTHORIZATION FORM?
In order to release patient protected health information for any reason other than treatment, payment and health care operations, we must have an authorization signed by the patient or the parent or guardian of the patient that clearly explains how they wish the information to be used and disclosed. The following are some examples of releases of information that require a separate authorization:
* Psychosocial information
* Use of information in scientific and educational publications, presentations and materials.
XI. CAN I CHANGE MY MIND AND REVOKE AN AUTHORIZATION?
You may change your mind and revoke an authorization, except (1) to the extent that we have relied on the authorization up to that point, (2) the information is needed to maintain the integrity of the research study, or (3) if the authorization was obtained as a condition of obtaining insurance coverage. All requests to revoke an authorization should be in writing.
XII. SHARING INFORMATION WITH BUSINESS ASSOCIATES
There are some services provided through contracts with business associates. Examples include billing services and transcription services. When these services are contracted, we may disclose your health information to the business associate so that they can perform the job we have contracted them to do.
XIII. WHEN IS MY AUTHORIZATION / CONSENT NOT REQUIRED?
The law requires that some information may be disclosed without your authorization in the following circumstances:
- In case of an emergency
- When there are communication or language barriers
- When required by law
- When there are risks to public health
- To conduct health oversight activities
- To report suspected child abuse or neglect or abuse/neglect to other disabled persons
- To specified government regulatory agencies
- In connection with judicial or administrative proceedings
- For law enforcement purposes
- To coroners, funeral directors, and for organ donation
- In the event of a serious threat to health or safety
XIV. YOUR PRIVACY RIGHTS
The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
1. You have the right to inspect and copy your health information. This means you may inspect and obtain a copy of your PHI that is contained in a "designated record set" for so long as we maintain the PHI. A designated record set contains medical and billing records and any other records that we use in making decisions about your healthcare. You may not however, inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding, and certain PHI that is subject to laws that prohibit access to that PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have the right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.
2. You have the right to request a restriction of your health information. This means you may ask us to restrict or limit the medical information we use or disclose for the purposes of treatment, payment or healthcare operations. We are not required to agree to a restriction that you may request. We will notify you if we deny your request. If we do agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction by contacting our Privacy Officer.
3. You have the right to request to receive confidential communications by alternative means or at alternative locations.
4. We will accommodate reasonable requests. We may also condition this accommodation by asking you for an alternative address or other method of contact. We will not request an explanation from you as the basis for the request. Requests must be made in writing to our Privacy Officer.
5. You have the right to request amendments to your health information. This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement with our Privacy Office and we may prepare a rebuttal to your statement and will provide you with a copy of this rebuttal. If you wish to amend your PHI, please contact our Privacy Officer. Requests for amendment must be in writing.
6. You have the right to receive an accounting of disclosures of your health information.
7. You have the right to request an accounting of certain disclosures of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, to family or friends involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. Accounting requests may not be made for periods of time in excess of six years.
8. You have the right to receive a paper copy of this Notice of Privacy Practices upon request.
XV. WHAT IF I HAVE A QUESTION / COMPLAINT?
If you have questions regarding your privacy rights, please contact the practice's Privacy Officer at 541-868-2004. If you believe your privacy rights have been violated, you may file a complaint by contacting practice's Privacy Officer at 541-868-2004 or the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. The address for the Secretary of the Department of Health and Human Services is: Office of Civil Rights, U.S. Department of Health and Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth St., S.W. Atlanta, GA 30303-8909
(404) 562-7886 (phone) | (404) 562-7881 (fax) | (404) 331-2867 (TDD) | www.hhs.gov/ocr/hipaa
VIDEO TELEHEALTH PATIENT INFORMED CONSENT AGREEMENT
Telehealth is the delivery of mental health services using interactive audio and visual electronic systems where the mental health provider and the patient are not in the same physical location. The interactive electronic systems used in telehealth incorporate network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.
Potential benefits include ncreased accessibility to mental healthcare and patient convenience.
Potential Risks. As with any behavioral health procedure, there may be potential risks associated with the use of telehealth. These risks include, but may not be limited to:
- Information transmitted may not be sufficient (e.g., poor resolution of video) to allow for appropriate mental health decision making by your telehealth provider.
- Your telehealth provider may not be able to provide mental health treatment using interactive electronic equipment nor provide for or arrange for emergency care that you may require.
- Delays in mental health evaluation and treatment may occur due to deficiencies or failures of the equipment.
- Security protocols can fail, causing a breach of privacy of my confidential mental health information.
- A lack of access to all the information that might be available in a face to face visit but not in a telehealth session may result in errors in mental health judgment.
Alternatives to the use of telehealth: Traditional face to face sessions in our Oregon offices.
Your Rights
- You understand that the laws that protect the privacy and confidentiality of mental health information also apply to telehealth.
- You understand that the technology used by Eugene Therapy and Oregon Counseling is encrypted to prevent the unauthorized access to your private mental health information.
- You have the right to withhold or withdraw your consent to the use of telehealth during the course of your care at any time. You understand that your withdrawal of consent will not affect any future care or treatment.
- You understand that your provider has the right to withhold or withdraw his consent for the use of telehealth during the course of your care at any time.
- You understand that the rules and regulations which apply to the practice of psychotherapy and psychiatry in the state of Oregon also apply to telehealth.
Your Responsibilities
- You will not record any telehealth sessions without written consent from your provider. You understand that your provider will not record any of our telehealth sessions without your written consent.
- You will inform your provider if any other person can hear or see any part of our session before the session begins.
- Your provider will inform you if any other person can hear or see any part of our session before the session begins.
- You understand that you, not your provider, are responsible for the configuration of any electronic equipment used on your computer which is used for telehealth. You understand that it is your responsibility to ensure the proper functioning of all electronic equipment before your session begins.
- You understand that you must be a resident of the state of Oregon to be eligible for telehealth services from your provider.
- You understand that your initial evaluation will not be done by telehealth except in special circumstances under which
- You will be required to verify your identity to your provider’s satisfaction.
- You authorize your insurance to be billed for your telehealth sessions.
- You agree to assume financial responsibility for any and all charges your health insurance company does not pay for telehealth services. This includes patient co-pay, co-insurance, policy deductible, and any and all non-covered services and the outstanding balance after the insurance company has submitted payment to Eugene Therapy/Oregon Counseling.
YOU CONSENT TO MENTAL HEALTH TREATMENT AND CONSENT TO ALL TERMS AND CONDITIONS OF THE ABOVE INTAKE DOCUMENTATION. YOU UNDERSTAND THAT EUGENE THERAPY/OREGONCOUNSELING RESERVES THE EXCLUSIVE RIGHT TO ACCEPT OR DENY YOU AS A NEW PATIENT AND THAT ACCEPTANCE OR DENIAL OF NEW PATIENT STATUS WILL ONLY BE COMMUNICATED ONCE WE REVIEW THE INFORMATION YOU PROVIDED IN THIS ELECTRONIC DOCUMENT.
Your electronic signature below indicates that:
- You have read the PATIENT AGREEMENT AND INFORMED CONSENT portion of this document and agree to all terms listed within. It also serves as an acknowledgment that you have received the HIPAA Notice Form described above.
- You have read the PRIVACY PRACTICES portion of this document and agree to all terms listed within.
- You have read the above FINANCIAL POLICY portion of this document and agree to all terms listed within.
- You have read the CHILD TREATMENT POLICY AND PARENTAL AGREEMENT TO CHILD’S PRIVACY portion of this document and agree to all applicable terms listed within and above.
- You have read the TELEHEALTH AGREEMENT AND INFORMED CONSENT and consent to the use of telehealth in your mental healthcare and authorize Eugene Therapy and Oregon Counseling, to use telehealth in the course of your diagnosis and treatment.
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